Willingness to Participate Form

62nd Annual Spring Meeting - 2022

April 28-30, 2022
Virtual - On Demand • Carlsbad, CA

WILLINGNESS TO PARTICIPATE FORM

WP FORM FOR: Thomas Dwyer, MD
If you are not Thomas Dwyer, MD click here | Return to Faculty Forms.

Contact Information

Required fields are marked with an "*".

Name: Thomas Dwyer, MD
Academic Title:*
Academic Institution:*
Academic Institution City/State:
Preferred Mailing Address:*
Phone Number:
Fax Number:
E-mail Address:*
Admin Assistant Name:
Admin Assistant Phone:
Willingness To Participate/Adherence To Deadlines

I have read the Willingness to Participate information below. These assignments have been made as a result of an invitation to perform the duties as a faculty member for the above-captioned meeting.

Please indicate your participation in the following lectures, workshops, case discussions, and/or as moderator as outlined in the lecture schedule.

Participation Date   Lecture Title
I will be lecturing:
 In-person
 Virtually
I am pleased to participate in all lectures, workshops, case discussions, and/or as moderator as outlined in the lecture schedule.

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I agree to adhere to all deadlines outlined in my faculty letter/email.